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Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29:170. [PMID: 34895311 PMCID: PMC8665507 DOI: 10.1186/s13049-021-00974-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinically meaningful pain reduction with respect to severity and the adverse events of drugs used in prehospital pain management for children are areas that have not received sufficient attention. The present systematic review therefore aims to perform a comprehensive search of databases to examine the preferable drugs for prehospital pain relief in paediatric patients with acute pain, irrespective of aetiology. METHODS The systematic review includes studies from 2000 and up to 2020 that focus on children's prehospital pain management. The study protocol is registered in PROSPERO with registration no. CRD42019126699. Pharmacological pain management using any type of analgesic drug and in all routes of administration was included. The main outcomes were (1) measurable pain reduction (effectiveness) and (2) no occurrence of any serious adverse events. Searches were conducted in PubMed, Medline, Embase, CINAHL, Epistemonikos and Cochrane library. Finally, the risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist and a textual narrative analysis was performed due to the heterogeneity of the results. RESULTS The present systematic review on the effectiveness and safety of analgesic drugs in prehospital pain relief in children identified a total of eight articles. Most of the articles reviewed identified analgesic drugs such as fentanyl (intranasal/IV), morphine (IV), methoxyflurane (inhalational) and ketamine (IV/IM). The effects of fentanyl, morphine and methoxyflurane were examined and all of the included analgesic drugs were evaluated as effective. Adverse events of fentanyl, methoxyflurane and ketamine were also reported, although none of these were considered serious. CONCLUSION The systematic review revealed that fentanyl, morphine, methoxyflurane and combination drugs are effective analgesic drugs for children in prehospital settings. No serious adverse events were reported following the administration of fentanyl, methoxyflurane and ketamine. Intranasal fentanyl and inhalational methoxyflurane seem to be the preferred drugs for children in pre-hospital settings due to their ease of administration, similar effect and safety profile when compared to other analgesic drugs. However, the level of evidence (LOE) in the included studies was only three or four, and further studies are therefore necessary.
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Affiliation(s)
- Yonas Abebe
- Department of Emergency and Critical Care Nursing, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway.
| | - Fredrik Hetmann
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
| | | | - Matt Holland
- Library and Knowledge Services for NHS Ambulance Services in England, Bolton, UK
| | - Trine Staff
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
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Houze-Cerfon CH, Balen F, Houze-Cerfon V, Motuel J, Battefort F, Bounes V. Hydroxyzine for lowering patient's anxiety during prehospital morphine analgesia: A prospective randomized double blind study. Am J Emerg Med 2021; 50:753-757. [PMID: 34879499 DOI: 10.1016/j.ajem.2021.09.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022] Open
Abstract
STUDY OBJECTIVE Hydroxyzine is an antihistamine drug used for symptomatic relief of anxiety and tension. We hypothesized that managing the anxiety of patients with severe pain by adding hydroxyzine to a conventional intravenous morphine titration would relieve their pain more effectively. METHODS This was a randomized, double-blind, controlled group study of prehospital patients with acute pain scored greater than or equal to 6 on a 0-10 verbal numeric rating scale (NRS). Patients'anxiety was measured with the self-reported Face Anxiety Scale (FAS) ranking from 0 to 4. The percentage of patients with pain relief (NRS score ≤ 3) 15 min after the first injection was the primary outcome. RESULTS One hundred forty patients were enrolled. Fifty-one percent (95% CI 39% to 63%) of hydroxyzine patients versus 52% (95% CI 40% to 64%) of placebo patients reported a pain numeric rating scale score of 3 or lower at 15 min. Ninety-one percent (95% CI 83% to 98%) of patients receiving hydroxyzine reported no more severe anxiety versus 78% (95% CI 68% to 88%) of patients with placebo (p > 0.05). Adverse events were minor, with no difference between groups (6% in hydroxyzine patients and 14% in placebo patients). CONCLUSION Addition of hydroxyzine to morphine in the prehospital setting did not reduce pain or anxiety in patients with acute severe pain and therefore is not indicated based on our results.
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Affiliation(s)
- Charles-Henri Houze-Cerfon
- Emergency Department, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France; UMR EFTS Université de Toulouse 2 Jean Jaurès, Toulouse, France
| | - Frédéric Balen
- Emergency Department, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France
| | - Vanessa Houze-Cerfon
- Emergency Department, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France; SAMU 31, Pôle Médecine d'Urgence, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France.
| | - Julie Motuel
- Anesthesiology Department, Centre Hospitalier Yves Le Foll, Saint Brieuc 22000, United States of America
| | - Florent Battefort
- SAMU 31, Pôle Médecine d'Urgence, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France
| | - Vincent Bounes
- SAMU 31, Pôle Médecine d'Urgence, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France
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Puntillo F, Giglio M, Varrassi G. The Routes of Administration for Acute Postoperative Pain Medication. Pain Ther 2021; 10:909-925. [PMID: 34273095 PMCID: PMC8586059 DOI: 10.1007/s40122-021-00286-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/24/2021] [Indexed: 11/24/2022] Open
Abstract
Effective treatment of postoperative acute pain, together with early mobilization and nutrition, is one of the perioperative strategies advocated to improve surgical outcome and reduce the costs of hospitalization. Moreover, adequate pain control reduces perioperative morbidity related to surgical stress and can also prevent the incidence of chronic postoperative pain syndromes, whose treatment is still a challenge. The choice of the most appropriate analgesics depends not only on the drug class, but also on the most suitable route of administration, the best dosage for that route, and unique limitations and contraindications for every patient. In the present review, a comprehensive analysis was performed on the different routes of administration of acute postoperative pain medications and their indications and limitations, focusing on recent evidence and international recommendations.
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Affiliation(s)
- Filomena Puntillo
- Department of Interdisciplinary Medicine, "Aldo Moro" University of Bari, Bari, Italy. .,Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy.
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Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. Guidelines for the acute care of severe limb trauma patients. Anaesth Crit Care Pain Med 2021; 40:100862. [PMID: 34059492 DOI: 10.1016/j.accpm.2021.100862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
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Affiliation(s)
- Julien Pottecher
- Service d'Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg Cedex, France; Université de Strasbourg, FMTS, France.
| | - Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, BP 9000, 57077 Metz Cédex 03, France
| | - Philippe Adam
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte Anne, 2 boulevard Sainte Anne, 83000 Toulon, France; Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
| | - Jonathan Charbit
- Soins critiques DAR Lapeyronie, CHU Montpellier, France; Réseau OcciTRAUMA, Réseau Régional Occitanie de prise en charge des traumatisés sévères, France
| | - Michel Galinski
- Pôle urgences adultes - SAMU 33, Hôpital Pellegrin, CHU de Bordeaux 3300 Bordeaux, France; INSERM U1219, ISPED, Bordeaux Population Health Research Center INSERM U1219-"Injury Epidemiology Transport Occupation" Team, F-33076 Bordeaux Cedex, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHU Lille, F-59000 Lille, France
| | - Tobias Gauss
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Université de Paris, Paris, France
| | - Yannick Georg
- Service de Chirurgie Vasculaire et Transplantation Rénale, Hôpitaux Universitaire de Strasbourg, Strasbourg, France
| | - Sophie Hamada
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Anatole Harrois
- Département d'anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Romain Kedzierewicz
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Bureau de Médecine d'Urgence, Division Santé, Brigade de Sapeurs-Pompiers de Paris, 1 place Jules Renard, 75017 Paris, France
| | - Pierre Pasquier
- Département anesthésie-réanimation, Hôpital d'instruction des armées Percy, Clamart, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Bertrand Prunet
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Claire Roger
- Service de Réanimation Chirurgicale, Pôle Anesthésie Réanimation Douleur Urgence, CHU Carémeau, 30000 Nîmes, France
| | - Karim Tazarourte
- Service SAMU-Urgences, CHU Edouard Herriot, Hospices civils de Lyon, Lyon, France; Université Lyon 1 Hesper EA 7425, Lyon, France
| | - Stéphane Travers
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; 1ère Chefferie du Service de Santé, Villacoublay, France
| | - Lionel Velly
- Service d'Anesthésie Réanimation, CHU Timone Adultes, 264 rue St Pierre 13005 Marseille, France; MeCA, Institut de Neurosciences de la Timone - UMR 7289, Aix Marseille Université, Marseille, France
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux, Bordeaux Population Health - INSERM U1219 Université de Bordeaux, Equipe IETO, Bordeaux, France
| | - Hervé Quintard
- Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
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Prehospital intravenous fentanyl administered by ambulance personnel: a cluster-randomised comparison of two treatment protocols. Scand J Trauma Resusc Emerg Med 2019; 27:11. [PMID: 30732618 PMCID: PMC6367789 DOI: 10.1186/s13049-019-0588-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 01/14/2019] [Indexed: 12/03/2022] Open
Abstract
Background Prehospital acute pain is a frequent symptom that is often inadequately managed. The concerns of opioid induced side effects are well-founded. To ensure patient safety, ambulance personnel are therefore provided with treatment protocols with dosing restrictions, however, with the concomitant risk of insufficient pain treatment of the patients. The aim of this study was to investigate the impact of a liberal intravenous fentanyl treatment protocol on efficacy and safety measures. Methods A two-armed, cluster-randomised trial was conducted in the Central Denmark Region over a 1-year period. Ambulance stations (stratified according to size) were randomised to follow either a liberal treatment protocol (3 μg/kg) or a standard treatment protocol (2 μg/kg). The primary outcome was the proportion of patients with sufficient pan relief (numeric rating scale (NRS, 0–10) < 3) at hospital arrival. Secondary outcomes included abnormal vital parameters as proxy measures of safety. A multi-level mixed effect logistic regression model was applied. Results In total, 5278 patients were included. Ambulance personnel following the liberal protocol administered higher doses of fentanyl [117.7 μg (95% CI 116.7–118.6)] than ambulance personnel following the standard protocol [111.5 μg (95% CI 110.7–112.4), P = 0.0001]. The number of patient with sufficient pain relief at hospital arrival was higher in the liberal treatment group than the standard treatment group [44.0% (95% CI 41.8–46.1) vs. 37.4% (95% CI 35.2–39.6), adjusted odds ratio 1.47 (95% CI 1.17–1.84)]. The relative decrease in NRS scores during transport was less evident [adjusted odds ratio 1.18 (95% CI 0.95–1.48)]. The occurrences of abnormal vital parameters were similar in both groups. Conclusions Liberalising an intravenous fentanyl treatment protocol applied by ambulance personnel slightly increased the number of patients with sufficient pain relief at hospital arrival without compromising patient safety. Future efforts of training ambulance personnel are needed to further improve protocol adherence and quality of treatment. Trial registration ClinicalTrials.gov (NCT02914678). Date of registration: 26th September, 2016.
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Ricard-Hibon A, Chareyron A. État des lieux de la prise en charge de la douleur. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Le concept d’oligoanalgésie en structure d’urgences reste une réalité en France comme dans de nombreux pays qui publient sur le sujet. Les motifs de cette oligoanalgésie sont multiples, le plus souvent liés à des contraintes organisationnelles plus que médicales. Les solutions existent, et la douleur aiguë persistante ne doit plus être une fatalité en structure d’urgences. L’analyse des raisons de l’oligoanalgésie avec des audits ciblés et la mise en place de protocoles thérapeutiques locaux sont des prérequis à l’amélioration de la prise en charge. Les nouveaux enjeux de la médecine d’urgence, liés à l’augmentation constante de la sollicitation, mais également en lien avec l’évolution des techniques médicales et des compétences des équipes médicales et soignantes, donnent de nouvelles perspectives pour améliorer la qualité–sécurité de la prise en charge de la douleur en structure d’urgences.
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Krebs H, Perrin Bayard R, Bares A, Dahmani S, Story T, Claret PG, Bobbia X, de La Coussaye J. Délégation de l’évaluation et du traitement de la douleur à l’infirmier de Service mobile d’urgence et de réanimation : étude avant–après monocentrique. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction : La prise en charge de la douleur en médecine d’urgence préhospitalière est encore insuffisante. Cette étude a pour objectif d’évaluer les effets d’une délégation de l’évaluation et du traitement de la douleur à l’infirmier diplômé d’État (IDE) en Service mobile d’urgence et de réanimation (Smur) sur le suivi des recommandations de la Société française de médecine d’urgence (SFMU).
Méthode : Étude rétrospective de type avant–après réalisée au Smur du centre hospitalier universitaire (CHU) de Nîmes de janvier à mai 2017. Les IDE ont été formés, entre les deux phases, à un protocole de délégation de l’évaluation et du traitement de la douleur fondé sur les dernières recommandations.
Résultats : Cent quatre-vingt-un patients ont été inclus dans chaque groupe, 74 (40 %) femmes (âge moyen de 60 ± 18 ans). Les groupes étaient comparables à l’exception de la proportion d’interventions traumatologiques (11 % dans le groupe « avant » vs 20 % dans le groupe « après » ; p = 0,02). Les recommandations ont été respectées pour 12 (7 %) patients dans le groupe « avant », 21 (12 %) dans le groupe « après » (p = 0,10). Le seul facteur indépendant de respect des recommandations est le type d’intervention traumatologique (odds ratio = 9,7 ; intervalle de confiance à 95 % : [2,3–53,3] ; p < 0,01). Le nombre de patients ayant bénéficié d’une administration d’antalgique était respectivement de 55 (30 %) dans le groupe « avant » et de 73 (40 %) dans le groupe « après » (p = 0,05). La réévaluation de l’intensité douloureuse en fin de prise en charge a été consignée dans 11 (6 %) cas de la phase avant vs 38 (21 %) dans la phase après (p < 0,01). Dans le sous-groupe des patients n’ayant pas bénéficié de trinitrine, les recommandations ont été respectées respectivement pendant les phases « avant » et « après » chez 7 (6 %) patients vs 17 (14 % ; p = 0,03).
Conclusion : Malgré une augmentation du taux de prescription d’antalgiques et de réévaluation de la douleur, le protocole de délégation IDE n’a pas permis un meilleur respect des recommandations. L’établissement de protocoles spécifiques en fonction du type d’intervention, notamment traumatologique, pourrait être une piste de réflexion.
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Matthews R, McCaul M, Smith W. A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town. Afr J Emerg Med 2017; 7:24-29. [PMID: 30456102 PMCID: PMC6234150 DOI: 10.1016/j.afjem.2017.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 10/21/2016] [Accepted: 01/10/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa. METHODS A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider. RESULTS A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4). DISCUSSION Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.
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Affiliation(s)
- Ryan Matthews
- Cape Peninsula University of Technology, Department of Emergency Medical Care, PO Box 1906, Bellville 7535, South Africa
| | - Michael McCaul
- Stellenbosch University, Centre for Evidence-based Health Care (CEBHC), PO Box 241, Cape Town 800, South Africa
| | - Wayne Smith
- University of Cape Town, Division of Emergency Medicine and Provincial Government of the Western Cape, Private Bag x24, Bellville 7535, South Africa
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Bounes V, Charriton-Dadone B, Levraut J, Delangue C, Carpentier F, Mary-Chalon S, Houze-Cerfon V, Sommet A, Houze-Cerfon CH, Ganetsky M. Predicting morphine related side effects in the ED: An international cohort study. Am J Emerg Med 2016; 35:531-535. [PMID: 28117179 DOI: 10.1016/j.ajem.2016.11.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 11/18/2022] Open
Abstract
STUDY OBJECTIVES Morphine is the reference treatment for severe acute pain in an emergency department. The purpose of this study was to describe and analyse opioid-related ADRs (adverse drug reactions) in a large cohort of emergency department patients, and to identify predictive factors for those ADRs. METHODS In this prospective, observational, pharmaco-epidemiological international cohort study, all patients aged 18years or older who were treated with morphine were enrolled. The study was done in 23 emergency departments in the US and France. Baseline numerical rating scale score and initial and total doses of morphine titration were recorded. Logistic regression analysis was used to study the effects of demographic, clinical and medical history covariates on the occurrence of opioid-induced ADRs within 6h after treatment. RESULTS A total of 1128 patients were included over 10months. Median baseline initial pain scores were 8/10 (7-10) versus 3/10 (1-4) after morphine administration. Median titration duration was 10min (IQR, 1-30). The occurrence of opioid-induced ADRs was 25% and 2% were serious. Patients experienced mainly nausea and drowsiness. Medical history of travel sickness (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.01-2.86) and history of nausea or vomiting post morphine (OR, 3.86; 95% CI, 2.29-6.51) were independent predictors of morphine related ADRs. CONCLUSION Serious morphine related ADRs are rare and unpredictable. Prophylactic antiemetic therapy could be proposed to patients with history of travel sickness and history of nausea or vomiting in a postoperative setting or after morphine administration.
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Affiliation(s)
- Vincent Bounes
- Pôle Médecine d'Urgence, Hôpital Universitaire de Purpan, Toulouse 31059 Cedex 9, France; INSERM UMR 1027, Université Paul Sabatier, Toulouse 31000, France.
| | | | - Jacques Levraut
- Pôle Médecine d'Urgence, Hôpital Universitaire de Nice, Nice 06000, France
| | - Cyril Delangue
- Service d'Accueil des Urgences, Centre Hospitalier de Dunkerque, Dunkerque 59385, France
| | - Françoise Carpentier
- Pôle Urgences Médecine Aigüe, Hôpital Universitaire des Alpes, Grenoble 38043 Cedex 9, France
| | - Stéphanie Mary-Chalon
- Pôle Médecine d'Urgence, Centre Hospitalier Comminges Pyrénées, Saint-Gaudens 31806, France
| | - Vanessa Houze-Cerfon
- Pôle Médecine d'Urgence, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France
| | - Agnès Sommet
- Service de Pharmacologie Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmaco-épidémiologie et d'Informations sur e médicament, Hôpital Universitaire de Toulouse, Toulouse 31059 Cedex 9, France
| | | | - Michael Ganetsky
- Department of Emergency Medicine Administrative Offices, West CC-2, Beth Israel Deaconess Medical Center, 1 Deaconess Place, Boston, MA 02215, USA
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Blackman VS, Cooper BA, Puntillo K, Franck LS. Prevalence and Predictors of Prehospital Pain Assessment and Analgesic Use in Military Trauma Patients, 2010–2013. PREHOSP EMERG CARE 2016; 20:737-751. [DOI: 10.1080/10903127.2016.1182601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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MacKenzie M, Zed PJ, Ensom MHH. Opioid Pharmacokinetics-Pharmacodynamics. Ann Pharmacother 2016; 50:209-18. [DOI: 10.1177/1060028015625659] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Meghan MacKenzie
- Dalhousie University College of Pharmacy, Nova Scotia Health Authority, Central Zone,Pharmacy Department, Halifax, NS, Canada
| | - Peter J. Zed
- The University of British Columbia, Vancouver, BC, Canada
| | - Mary H. H. Ensom
- The University of British Columbia, Vancouver, BC, Canada
- Children’s and Women’s Health Centre of British Columbia, Vancouver, BC, Canada
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Strandmark R, Herlitz J, Axelsson C, Claesson A, Bremer A, Karlsson T, Jimenez-Herrera M, Ravn-Fischer A. Determinants of pre-hospital pharmacological intervention and its association with outcome in acute myocardial infarction. Scand J Trauma Resusc Emerg Med 2015; 23:105. [PMID: 26626732 PMCID: PMC4665872 DOI: 10.1186/s13049-015-0188-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was a) To identify predictors of the use of aspirin in the pre-hospital setting in acute myocardial infarction (AMI) and b) To analyze whether the use of any of the recommended medications was associated with outcome. METHODS All patients with a final diagnosis of AMI, transported by the Emergency Medical Services (EMS) and admitted to the coronary care unit at Sahlgrenska University Hospital in Gothenburg, Sweden, in 2009-2011, were included. RESULTS 1,726 patients were included. 58 % received aspirin by the EMS. Ischemic heart disease (IHD) was suspected in 84 %. Among patients who did not receive aspirin IHD was still suspected in 67 %. Among patients in whom IHD was suspected, and who were not on chronic treatment with aspirin the following predicted its pre-hospital use: a) age (odds ratio 0.98; 95 % confidence interval (CI) 0.96-0.99); b) a history of myocardial infarction (2.21; 1.21-4.04); c) priority given by EMS (8.07; 5.42-12.02); d) ST-elevation on ECG on admission to hospital (2.22; 1.50-3.29); e) oxygen saturation > 90 % (3.37; 1.81-6.27). After adjusting for confounders among patients who were not on chronic aspirin, only nitroglycerin of the recommended medications was associated with a reduced risk of death within 1 year (hazard ratio 0.40; 95 % CI 0.23-0.70). CONCLUSIONS Less than six out of ten patients with AMI received pre-hospital aspirin. Five clinical factors were independently associated with the pre-hospital administration of aspirin. This suggests that the decision to treat is multifactorial, and it highlights the lack of accurate diagnostic tools in the pre-hospital environment. Nitroglycerin was independently associated with a reduced risk of death, suggesting that we select the use for a low-risk cohort.
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Affiliation(s)
- Rasmus Strandmark
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Johan Herlitz office, Registercentrum i Västra Götaland, 413 45, Gothenburg, Sweden.
| | - Johan Herlitz
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Christer Axelsson
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Andreas Claesson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden.
| | - Anders Bremer
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Thomas Karlsson
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | | | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Sudrial J, Combes X. Prise en charge de la douleur aux urgences. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1109-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Grissa MH, Boubaker H, Zorgati A, Beltaïef K, Zhani W, Msolli MA, Bzeouich N, Bouida W, Boukef R, Nouira S. Efficacy and safety of nebulized morphine given at 2 different doses compared to IV titrated morphine in trauma pain. Am J Emerg Med 2015; 33:1557-61. [PMID: 26143313 DOI: 10.1016/j.ajem.2015.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 06/04/2015] [Accepted: 06/04/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Our aim was to compare the efficacy and safety of intravenous (IV) titrated morphine with nebulized morphine given at 2 different doses in severe traumatic pain. METHODS In a prospective, randomized, controlled double-blind study, we included 300 patients with severe traumatic pain. They were assigned to 3 groups: Neb10 group received 1 nebulization of 10-mg morphine; Neb20 group received 1 nebulization of 20-mg morphine, repeated every 10 minutes with a maximum of 3 nebulizations; and the IV morphine group received 2-mg IV morphine repeated every 5 minutes until pain relief. Visual analog scale was monitored at baseline, 5, 10, 15, 20, 25, 30, and 60 minutes after the start of drug administration. Treatment success was defined by the percentage of patients in whom visual analog scale decreased greater than or equal to 50% of its baseline value. When this end point was not reached, rescue morphine was administered. Pain resolution time was defined by the elapsed time between the start of the protocol and the reach of treatment success criteria. RESULTS Success rate was significantly better at 97% (95% confidence interval [CI], 93-100) for Neb20 group compared to Neb10 group (81% [95% CI, 73-89]) and IV morphine group (79% [95% CI, 67-84]). The lowest resolution time was observed in Neb20 group (20 minutes [95% CI, 18-21]). Side effects were minor and significantly lower in both nebulization groups compared to IV morphine group. CONCLUSIONS Nebulized morphine using boluses of 10 mg has similar efficacy and better safety than IV titrated morphine in patients with severe posttraumatic pain. Increasing nebulized boluses to 20 mg increases the effectiveness without increasing side effects.
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Affiliation(s)
- Mohamed Habib Grissa
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Hamdi Boubaker
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Asma Zorgati
- Emergency Department, Sahloul University Hospital, Sousse, Tunisia
| | - Kaouthar Beltaïef
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Wafa Zhani
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | | | - Nasri Bzeouich
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Wahid Bouida
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Riadh Boukef
- Emergency Department, Sahloul University Hospital, Sousse, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
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Vincent-Lambert C, de Kock JM. Use of morphine sulphate by South African paramedics for prehospital pain management. Pain Res Manag 2015; 20:141-4. [PMID: 25996767 PMCID: PMC4447157 DOI: 10.1155/2015/507470] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Evidence in the literature highlights the fact that acute pain in the prehospital setting remains poorly managed. Morphine remains the most commonly used analgesic agent in the South African prehospital emergency care setting. Although guidelines and protocols relating to the dosage and administration of morphine exist, little data are available describing its use by South African paramedics. OBJECTIVES To document and describe the way in which morphine is administered by a sample of South African paramedics for the management of acute pain in the prehospital setting. METHODS An Internet-based survey was conducted. Sixty South African paramedics responded by completing the online questionnaire documenting and describing their use of morphine for management of acute pain. RESULTS Results revealed that participants appeared to be overly cautious of potential adverse effects associated with administration of morphine. Although the majority of participants calculated the dose of morphine to be administered correctly according to the patient's weight, the majority do not appear to be administering this as a bolus; rather, they administer the calculated loading dose in a titrated manner over time. This method may result in a delay and or failure to adequately achieve therapeutic serum levels. CONCLUSION Failure to administer an appropriate bolus or 'loading dose' when administering morphine intravenously may result in ineffective and delayed pain management. The authors recommend more clearly defined protocols be developed to guide the use of morphine sulphate by paramedics in the local emergency medical services environment.
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Affiliation(s)
- Craig Vincent-Lambert
- Department of Emergency Medical Care and Podiatry, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Joalda Marthiné de Kock
- Department of Emergency Medical Care and Podiatry, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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Ahmad S, De Oliveira GS, Bialek JM, McCarthy RJ. Thermal Quantitative Sensory Testing to Predict Postoperative Pain Outcomes Following Gynecologic Surgery. PAIN MEDICINE 2014; 15:857-864. [DOI: 10.1111/pme.12374] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Auffret Y, Gouillou M, Jacob GR, Robin M, Jenvrin J, Soufflet F, Alavi Z. Does midazolam enhance pain control in prehospital management of traumatic severe pain? Am J Emerg Med 2014; 32:655-9. [PMID: 24613655 DOI: 10.1016/j.ajem.2014.01.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/07/2014] [Accepted: 01/28/2014] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Midazolam comedication with morphine is a routine practice in pre and postoperative patients but has not been evaluated in prehospital setting. We aimed to evaluate the comedication effect of midazolam in the prehospital traumatic adults. METHODS A prehospital prospective randomized double-blind placebo-controlled trial of intravenous morphine 0.10 mg/kg and midazolam 0.04 mg/kg vs morphine 0.10 mg/kg and placebo. Pain assessment was done using a validated numeric rating scale (NRS). The primary end point was to achieve an efficient analgesic effect (NRS≤3) 20 minutes after the baseline. The secondary end points were treatment safety, total morphine dose required until obtaining NRS≤3, and efficient analgesic effect 30 minutes after the baseline. FINDINGS Ninety-one patients were randomized into midazolam (n=41) and placebo (n=50) groups. No significant difference in proportion of patients with a pain score≤3 was observed between midazolam (43.6%) and placebo (45.7%) after 20 minutes (P=.849). Secondary end points were similar in regard with proportion of patients with a pain score≤3 at T30, the side effects and adverse events except for drowsiness in midazolam vs placebo, 43.6% vs 6.5% (P<.001). No significant difference in total morphine dose was observed, that is, midazolam (14.09 mg±6.64) vs placebo (15.53 mg±6.27) (P=.315). CONCLUSIONS According to our study, midazolam does not enhance pain control as an adjunctive to morphine regimen in the management of trauma-induced pain in prehospital setting. However, such midazolam use seems to be associated with an increase in drowsiness.
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Affiliation(s)
- Yannick Auffret
- Quimper Hospital CHIC, Emergency Department SMUR, Quimper 29000
| | | | | | | | - Joël Jenvrin
- Nantes Medical University Hospital, SAMU, Nantes 44000
| | | | - Zarrin Alavi
- INSERM CIC 0502, Brest Medical University Hospital, Brest 29200.
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Baharuddin KA, Rahman NHN, Wahab SFA, Halim NA, Ahmad R. Intravenous parecoxib sodium as an analgesic alternative to morphine in acute trauma pain in the emergency department. Int J Emerg Med 2014; 7:2. [PMID: 24386899 PMCID: PMC3891999 DOI: 10.1186/1865-1380-7-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 12/16/2013] [Indexed: 12/02/2022] Open
Abstract
Background Parecoxib sodium is the first parenteral COX-2 inhibitor used for pain management licensed for postoperative pain. However, no study has assessed the usage of parecoxib for acute traumatic pain in the emergency department (ED). The objective of this study was to investigate a potential alternative analgesic agent in the ED by determining the mean reduction of pain score between acute traumatic pain patients who were administered with intravenous (IV) parecoxib sodium versus IV morphine sulfate. The onset of perceptible analgesic effect and side effects were also evaluated. Methods A randomized, double-blinded study comparing IV parecoxib 40 mg versus IV morphine at 0.10 mg/kg was conducted in adult patients presented with acute traumatic pain with numeric rating scale (NRS) of 6 or more within 6 hours of injury. Patients were randomized using a computer-generated randomization plan. Drug preparation and dispensing were performed by a pharmacist. Periodic assessment of blood pressure, pulse rate, oxygen saturation, and NRS were taken at 0, 5, 15, and 30 minute intervals after the administration of the study drug. The primary outcome was the reduction of NRS. Side effect and drug evaluation was conducted within 30 minutes of drug administration. Results There was no statistically significant difference in the reduction of mean NRS between patients in the IV parecoxib group or IV morphine group (P = 0.095). The mean NRS for patients treated with IV morphine were 7.1 at 0 minutes, 4.5 at 5 minutes, 3.1 at 15 minutes, and 2.0 at 30 minutes. Whereas mean NRS for patients who received IV parecoxib were 7.8 at 0 minutes, 5.7 at 5 minutes, 4.7 at 15 minutes, and 3.9 at 30 minutes. The onset of perceptible analgesic effects could be seen as early as 5 minutes. Dizziness was experienced in 42.9% of patients who received IV morphine compared to none in the parecoxib group. Conclusions There was non-significant trend toward superiority of IV morphine over IV parecoxib. Looking at its effectiveness and the lack of opioid-related side-effects, the usage of IV parecoxib sodium may be extended further to a variety of cases in the ED.
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Affiliation(s)
- Kamarul Aryffin Baharuddin
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kelantan, Malaysia.
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Gausche-Hill M, Brown KM, Oliver ZJ, Sasson C, Dayan PS, Eschmann NM, Weik TS, Lawner BJ, Sahni R, Falck-Ytter Y, Wright JL, Todd K, Lang ES. An Evidence-based Guideline for prehospital analgesia in trauma. PREHOSP EMERG CARE 2013; 18 Suppl 1:25-34. [PMID: 24279813 DOI: 10.3109/10903127.2013.844873] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols. OBJECTIVE To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. Methods. We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major children's research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council. RESULTS Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales. CONCLUSION GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.
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Dijkstra BM, Berben SAA, van Dongen RTM, Schoonhoven L. Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands. Eur J Pain 2013; 18:3-19. [PMID: 23737462 DOI: 10.1002/j.1532-2149.2013.00337.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2013] [Indexed: 12/26/2022]
Abstract
Pain is one of the main complaints of trauma patients in (pre-hospital) emergency medicine. Significant deficiencies in pain management in emergency medicine have been identified. No evidence-based protocols or guidelines have been developed so far, addressing effectiveness and safety issues, taking the specific circumstances of pain management of trauma patients in the chain of emergency care into account. The aim of this systematic review was to identify effective and safe initial pharmacological pain interventions, available in the Netherlands, for trauma patients with acute pain in the chain of emergency care. Up to December 2011, a systematic search strategy was performed with MeSH terms and free text words, using the bibliographic databases CINAHL, PubMed and Embase. Methodological quality of the articles was assessed using standardized evaluation forms. Of a total of 2328 studies, 25 relevant studies were identified. Paracetamol (both orally and intravenously) and intravenous opioids (morphine and fentanyl) proved to be effective. Non-steroidal anti-inflammatory drugs (NSAIDs) showed mixed results and are not recommended for use in pre-hospital ambulance or (helicopter) emergency medical services [(H)EMS]. These results could be used for the development of recommendations on evidence-based pharmacological pain management and an algorithm to support the provision of adequate (pre-hospital) pain management. Future studies should address analgesic effectiveness and safety of various drugs in (pre-hospital) emergency care. Furthermore, potential innovative routes of administration (e.g., intranasal opioids in adults) need further exploration.
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Affiliation(s)
- B M Dijkstra
- Department of Critical Care, Radboud University Nijmegen Medical Centre, The Netherlands; HAN University of Applied Sciences, Nijmegen, The Netherlands
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Ducassé JL, Siksik G, Durand-Béchu M, Couarraze S, Vallé B, Lecoules N, Marco P, Lacombe T, Bounes V. Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial. Acad Emerg Med 2013; 20:178-84. [PMID: 23406077 DOI: 10.1111/acem.12072] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/08/2012] [Accepted: 09/09/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Although 50% nitrous oxide (N(2) O) and oxygen is a widely used treatment, its efficacy had never been evaluated in the prehospital setting. The objective of this study was to demonstrate the efficacy of premixed N(2) O and oxygen in patients with out-of-hospital moderate traumatic acute pain. METHODS This prospective, randomized, multicenter, double-blind trial enrolled patients with acute moderate pain (numeric rating scale [NRS] score between 4 and 6 out of 10) caused by trauma. Patients were assigned to receive either 50/50 N(2) O and oxygen 9 L/min (N(2) O group) or medical air (MA) 9 L/min (MA group), in ambulances from two nurse-staffed fire department centers. After the first 15 minutes, every patient received N(2) O and oxygen. The primary endpoint was pain relief at 15 minutes (T15), defined as a NRS ≤ 3 of 10. The NRS was measured every 5 minutes. Secondary endpoints were treatment safety and adverse events, time to analgesia, and patient and investigator satisfaction with analgesia. RESULTS Sixty patients were included with no differences between groups in age (median = 34 years, interquartile range [IQR] = 23 to 53 years), sex (37 males, 66%), and initial median NRS of 6 (IQR = 5 to 6). At T15, 67% of the patients in the N(2) O group had an NRS score of 3 or lower versus 27% of those in the MA group (delta = 40%, 95% confidence interval [CI] = 17% to 63%; p < 0.001). The median pain scores were lower in the N(2) O group at T15, 2 (IQR = 1 to 4) versus 5 (IQR = 3 to 6). There was a difference at 5 minutes that persisted at all subsequent time points. Four patients (one in the N(2) O group) experienced adverse events (nausea) during the protocol. CONCLUSIONS This study demonstrates the efficacy of N(2) O for the treatment of pain from acute trauma in adults in the prehospital setting.
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Affiliation(s)
- Jean-Louis Ducassé
- Service d'Aide Médicale Urgente de la Haute Garonne (SAMU 31); Hôpital Universitaire de Purpan; Toulouse; France
| | - Georges Siksik
- The Service de Santé et de Secours Médical (SSSM) and the Service Départemental d'Incendie et de Secours de la Haute Garonne (SDIS 31); Colomiers; France
| | - Manon Durand-Béchu
- Service d'Aide Médicale Urgente de la Haute Garonne (SAMU 31); Hôpital Universitaire de Purpan; Toulouse; France
| | - Sébastien Couarraze
- The Service de Santé et de Secours Médical (SSSM) and the Service Départemental d'Incendie et de Secours de la Haute Garonne (SDIS 31); Colomiers; France
| | - Baptiste Vallé
- Service d'Aide Médicale Urgente de la Haute Garonne (SAMU 31); Hôpital Universitaire de Purpan; Toulouse; France
| | - Nathalie Lecoules
- The Service d'Accueil des Urgences; Hôpital Universitaire de Purpan; Toulouse; France
| | - Patrice Marco
- The Service de Santé et de Secours Médical (SSSM) and the Service Départemental d'Incendie et de Secours de la Haute Garonne (SDIS 31); Colomiers; France
| | - Thierry Lacombe
- The Service de Santé et de Secours Médical (SSSM) and the Service Départemental d'Incendie et de Secours de la Haute Garonne (SDIS 31); Colomiers; France
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Walsh B, Cone DC, Meyer EM, Larkin GL. Paramedic attitudes regarding prehospital analgesia. PREHOSP EMERG CARE 2012; 17:78-87. [PMID: 22971168 DOI: 10.3109/10903127.2012.717167] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Although pain is a major reason why patients summon emergency medical services (EMS), prehospital medical providers administer analgesic agents at inappropriately low rates. One possible reason is the role of EMS provider attitudes. OBJECTIVE This study was conducted to elicit attitudes that may act as impediments or deterrents to administering analgesia in the prehospital environment. METHODS A qualitative methodology was employed. We recruited experienced paramedics, with at least one year of full-time fieldwork, from a variety of agencies in New England. We sought to include a balance of rural and urban as well as both private and hospital-based agencies. Participants at each site were selected through purposive sampling. A semistructured discussion guide was designed to elicit the paramedics' past experiences with administering analgesia, as well as reflections on their role in the care of patients in pain. Both interviews and focus groups were conducted. These sessions were recorded and transcribed verbatim. The transcripts were topic-analyzed and iteratively coded by two independent investigators utilizing the constant comparative method of Glaser and Strauss' Grounded Theory; coding ambiguities were resolved by consensus. Through a series of conceptual mapping and iterative code refinement, themes and domains were generated. RESULTS Fifteen paramedics from five EMS agencies in three New England states were recruited. Major themes were: 1) a reluctance to administer opioids to patients without significant objective signs (e.g., deformity, hypertension); 2) a preoccupation with potential malingering; 3) ambivalence about the degree of pain control to target or to expect (e.g., aiming to "take the edge off"); 4) a fear of masking diagnostic symptoms; and 5) an aversion to aggressive dosing of opioids (e.g., initial doses of morphine did not exceed 5 mg). CONCLUSIONS A number of potentially modifiable attitudinal barriers to appropriate pain management were revealed.
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Affiliation(s)
- Brooks Walsh
- Yale-New Haven Medical Center Emergency Medicine Residency Program, Yale University School of Medicine, New Haven, CT 06519,
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Prehospital nausea and vomiting after trauma: Prevalence, risk factors, and development of a predictive scoring system. J Trauma Acute Care Surg 2012; 72:1249-53; discussion 1253-4. [PMID: 22673251 DOI: 10.1097/ta.0b013e318249668e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nausea and vomiting are common problems in trauma patients and potentially dangerous during trauma resuscitation. These symptoms are present in up to 10% of ambulance patients, but their prevalence in trauma patients is largely unknown. The aim of this study was to determine the prevalence of prehospital nausea and vomiting in trauma patients and evaluate antiemetic usage. METHODS Prospective, cohort study of trauma resuscitation patients transported by ambulance to a major trauma centre. Patients with hemodynamic instability (systolic blood pressure <90, heart rate >120) or Glasgow Coma Scale score <14 on arrival were excluded. Nausea, vomiting, and antiemetic use were recorded. RESULTS Convenience sample of 196 trauma resuscitation patients (68% men; age, 42 ± 18 years, mean Injury Severity Score 8 ± 7) were interviewed over the 5-month study period, of a total 369 admitted trauma patients (53%). Seventy-five (38%) patients reported some degree of nausea, 57 (29%) moderate or severe nausea, and 15 (8%) vomited. Older age and female gender were associated with vomiting (p < 0.01). Seventy-nine patients (40%) received a prophylactic antiemetic. Of these, four became nauseous (5%), compared with 71 of 117 (61%) for patients not given an antiemetic (p < 0.0001). CONCLUSIONS Prehospital nausea and vomiting are more common in our cohort of trauma patients than the reported rates in the literature for nontrauma patients transported to hospital by ambulance. Only 40% of patients receive prophylactic antiemetics, but those patients are less likely to develop symptoms. LEVEL OF EVIDENCE V, epidemiological study.
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Smith MD, Wang Y, Cudnik M, Smith DA, Pakiela J, Emerman CL. The Effectiveness and Adverse Events of Morphine versus Fentanyl on a Physician-staffed Helicopter. J Emerg Med 2012; 43:69-75. [DOI: 10.1016/j.jemermed.2011.05.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 10/14/2010] [Accepted: 05/19/2011] [Indexed: 11/15/2022]
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Sédation et analgésie en structure d’urgence. Quelles sédation et analgésie chez le patient en ventilation spontanée en structure d’urgence ? ACTA ACUST UNITED AC 2012; 31:295-312. [DOI: 10.1016/j.annfar.2012.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Aubrun F, Mazoit JX, Riou B. Postoperative intravenous morphine titration. Br J Anaesth 2012; 108:193-201. [DOI: 10.1093/bja/aer458] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Niemi-Murola L, Unkuri J, Hamunen K. Parenteral opioids in emergency medicine - A systematic review of efficacy and safety. Scand J Pain 2011; 2:187-194. [PMID: 29913751 DOI: 10.1016/j.sjpain.2011.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 05/28/2011] [Indexed: 02/07/2023]
Abstract
Introduction and aim Pain is a frequent symptom in emergency patients and opioids are commonly used to treat it at emergency departments and at pre-hospital settings. The aim of this systematic review is to examine the efficacy and safety of parenteral opioids used for acute pain in emergency medicine. Method Qualitative review of randomized controlled trials (RCTs) on parenteral opioids for acute pain in adult emergency patients. Main outcome measures were: type and dose of the opioid, analgesic efficacy as compared to either placebo or another opioid and adverse effects. Results Twenty double-blind RCTs with results on 2322 patients were included. Seven studies were placebo controlled. Majority of studies were performed in the emergency department. Only five studies were in prehospital setting. Prehospital studies Four studies were on mainly trauma-related pain, one ischemic chest pain. One study compared two different doses of morphine in mainly trauma pain showing faster analgesia with the larger dose but no difference at 30 min postdrug. Three other studies on the same pain model showed equal analgesic effects with morphine and other opioids. Alfentanil was more effective than morphine in ischemic chest pain. Emergency department studies Pain models used were acute abdominal pain seven, renal colic four, mixed (mainly abdominal pain) three and trauma pain one study. Five studies compared morphine to placebo in acute abdominal pain and in all studies morphine was more effective than placebo. In four out of five studies on acute abdominal pain morphine did not change diagnostic accuracy, clinical or radiological findings. Most commonly used morphine dose in the emergency department was 0.1 mg/kg (five studies). Other opioids showed analgesic effect comparable to morphine. Adverse effects Recording and reporting of adverse effects was very variable. Vital signs were recorded in 15 of the 20 studies (including all prehospital studies). Incidence of adverse effects in the opioid groups was 5-38% of the patients in the prehospital setting and 4-46% of the patients in the emergency department. Nausea or vomiting was reported in 11-25% of the patients given opioids. Study drug was discontinued because of adverse effects five patients (one placebo, two sufentanil, two morphine). Eight studies commented on administration of naloxone for reversal of opioid effects. One patient out of 1266 was given naloxone for drowsiness. Ventilatory depression defined by variable criteria occurred in occurred in 7 out of 756 emergency department patients. Conclusion Evidence for selection of optimal opioid and dose is scarce. Opioids, especially morphine, are effective in relieving acute pain also in emergency medicine patients. Studies so far are small and reporting of adverse effects is very variable. Therefore the safety of different opioids and doses remains to be studied. Also the optimal titration regimens need to be evaluated in future studies. The prevention and treatment of opioid-induced nausea and vomiting is an important clinical consideration that requires further clinical and scientific attention in this patient group.
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Affiliation(s)
- Leila Niemi-Murola
- Department of Anaesthesiology and Intensive Care Medicine, P.O. Box 20, University of Helsinki, 00014Helsinki, Finland.,Meilahti Hospital, Department of Anaesthesiology and Intensive Care Medicine, P.O. Box 340, Helsinki University Hospital, 00029 HUS, Helsinki, Finland
| | - Jani Unkuri
- Department of Anaesthesiology and Intensive Care Medicine, P.O. Box 20, University of Helsinki, 00014Helsinki, Finland
| | - Katri Hamunen
- Meilahti Hospital, Department of Anaesthesiology and Intensive Care Medicine, P.O. Box 340, Helsinki University Hospital, 00029 HUS, Helsinki, Finland
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Simpson PM, Bendall JC, Middleton PM. Review article: Prophylactic metoclopramide for patients receiving intravenous morphine in the emergency setting: a systematic review and meta-analysis of randomized controlled trials. Emerg Med Australas 2011; 23:452-7. [PMID: 21824312 DOI: 10.1111/j.1742-6723.2011.01433.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The objective of the present study was to conduct a systematic review and meta-analysis of randomized controlled trials, comparing metoclopramide with placebo, for preventing vomiting in patients who have received i.v. morphine for acute pain in the emergency setting, and to determine the level of evidence supporting the use of prophylactic metoclopramide in this population. Comprehensive systematic electronic searches were conducted of MEDLINE, EMBASE and the Cochrane Library for randomized controlled trials addressing the clinical question. Reference lists of identified articles were hand-searched. Methodologically appropriate clinical trials identified in the search process were included in a meta-analysis to provide a pooled estimate of effect. Three randomized controlled trials fulfilled the search criteria. All three studies were included in the final meta-analysis that demonstrated an overall result of no difference between metoclopramide and placebo for the primary outcome of vomiting (odds ratios 0.72; 95% confidence intervals 0.11-4.58). There was little evidence that routine prophylactic administration of metoclopramide following the administration of i.v. morphine for acute pain management in the emergency setting is clinically beneficial. Routine metoclopramide administration might expose patients to a risk of harm which is not justifiable given a lack of evidence of benefit.
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Affiliation(s)
- Paul M Simpson
- Ambulance Research Institute, Ambulance Service of New South Wales, Rozelle, New South Wales, Australia.
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Quality of pain management in the emergency department: results of a multicentre prospective study. Eur J Anaesthesiol 2011; 28:97-105. [DOI: 10.1097/eja.0b013e3283418fb0] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park C, Roberts D, Aldington D, Moore R. Prehospital Analgesia: Systematic Review of Evidence. J ROY ARMY MED CORPS 2010; 156:295-300. [DOI: 10.1136/jramc-156-04s-05] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Is pre-hospital treatment of chest pain optimal in acute coronary syndrome? The relief of both pain and anxiety is needed. Int J Cardiol 2010; 149:147-151. [PMID: 21040986 DOI: 10.1016/j.ijcard.2010.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 06/09/2010] [Accepted: 10/05/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Many patients who suffer from acute chest pain are transported by ambulance. It is not known how often treatment prior to hospital admission is optimal and how optimal pain-relieving treatment is defined. It is often difficult to delineate pain from anxiety. AIM To describe various aspects of chest pain in the pre-hospital setting with the emphasis on a) treatment and b) presumed acute coronary syndrome. METHODS In the literature search, we used PubMed and the appropriate key words. We included randomised clinical trials and observational studies. RESULTS Four types of drug appear to be preferred: 1) narcotic analgesics, 2) nitrates, 3) beta-blockers and 4) benzodiazepines. Among narcotic analgesics, morphine has been associated with the relief of pain at the expense of side-effects. Alfentanil was reported to produce more rapid pain relief. Nitrates have been associated with the relief of pain with few side-effects. Beta-blockers have been reported to increase the relief of pain when added to morphine. The combination of beta-blockers and morphine has been reported to be as effective as beta-blockers alone in pain relief, but this combination therapy was associated with more side-effects. Experience from anxiety-relieving drugs such as benzodiazepines is limited. It is not known how these 4 drugs should be combined. The results indicate that various pain-relieving treatments might modify the disease. CONCLUSION Our knowledge of the optimal treatment of chest pain and associated anxiety in the pre-hospital setting is insufficient. Recommendations from existing guidelines are limited. Large randomised clinical trials are warranted.
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Intravenous opioid dosing and outcomes in emergency patients: a prospective cohort analysis. Am J Emerg Med 2010; 28:1041-1050.e6. [DOI: 10.1016/j.ajem.2009.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 06/23/2009] [Accepted: 06/24/2009] [Indexed: 11/18/2022] Open
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Bounes V, Concina F, Lecoules N, Olivier M, Lauque D, Ducassé JL. Le Smur meilleur vecteur pour une analgésie des patients traumatisés à l’arrivée aux urgences. ACTA ACUST UNITED AC 2010; 29:699-703. [DOI: 10.1016/j.annfar.2010.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 06/08/2010] [Indexed: 11/17/2022]
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Aspects on the intensity and the relief of pain in the prehospital phase of acute coronary syndrome: experiences from a randomized clinical trial. Coron Artery Dis 2010; 21:113-20. [PMID: 20124885 DOI: 10.1097/mca.0b013e32832fa9e5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The primary aim of this study was to evaluate the pain relief and tolerability of two pain-relieving strategies in the prehospital phase of presumed acute coronary syndrome (ACS), and the secondary aim was to assess the relationship between the intensity and relief of pain and heart rate, blood pressure, and ST deviation. Patients with chest pain judged as caused by ACS were randomized (open) to either metoprolol 5 mg intravenously (i.v.) three times at 2-min intervals (n = 84; metoprolol group) or morphine 5 mg i.v. followed by metoprolol 5 mg three times i.v (n = 80; morphine group). Pain was assessed on a 10-grade scale before randomization and 10, 20, and 30 min thereafter. The mean pain score decreased from 6.5 at randomization to 2.8 30 min later, with no significant difference between groups. The percentages with complete pain relief (pain score < or = 1) after 10, 20, and 30 min were 11, 16, and 21%, respectively, with no difference between groups. Hypotension was less frequent in the metoprolol group compared with the morphine group (0 vs. 6.3%; P=0.03), as was nausea/vomiting (7.2 vs. 24.0%; P=0.004). At randomization intensity of pain was associated with degree of ST elevation (P=0.009). The degree of pain relief over 30 min was associated with decrease in heart rate (P=0.03) and decrease in ST elevation (P=0.01).In conclusion, in the prehospital phase of presumed ACS, neither a pain-relieving strategy including an anti-ischemic agent alone nor an analgesic plus anti-ischemic strategy in combination resulted in complete pain relief. Fewer side effects were found with the former strategy. Other pain-relieving strategies need to be evaluated.
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Bounes V, Barthélémy R, Diez O, Charpentier S, Montastruc JL, Ducassé JL. Sufentanil is not superior to morphine for the treatment of acute traumatic pain in an emergency setting: a randomized, double-blind, out-of-hospital trial. Ann Emerg Med 2010; 56:509-16. [PMID: 20382445 DOI: 10.1016/j.annemergmed.2010.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Revised: 02/27/2010] [Accepted: 03/10/2010] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE We determine the best intravenous opioid titration protocol by comparing morphine and sufentanil for adult patients with severe traumatic acute pain in an out-of-hospital setting, with a physician providing care. METHODS In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older, with acute severe pain (defined as a numeric rating scale score ≥ 6/10) caused by trauma. They were assigned to receive either intravenous 0.15 μg/kg sufentanil, followed by 0.075 μg/kg every 3 minutes or intravenous 0.15 mg/kg morphine and then 0.075 mg/kg. The primary endpoint of the study was pain relief at 15 minutes, defined as a numeric rating scale less than or equal to 3 of 10. Secondary endpoints were time to analgesia, adverse events, and duration of analgesia during the first 6 hours. RESULTS A total of 108 patients were included, 54 in each group. At 15 minutes, 74% of the patients in the sufentanil group had a numeric rating scale score of 3 or lower versus 70% of those in the morphine group (Δ4%; 95% confidence interval -13% to 21%). At 9 minutes, 65% of the patients in the sufentanil group experienced pain relief versus 46% of those in the morphine group (Δ18%; 95% confidence interval 0.1% to 35%). The duration of analgesia was in favor of the morphine group. Nineteen percent of patients experienced an adverse event in both groups, all mild to moderate. CONCLUSION Intravenous morphine titration using a loading dose of morphine followed by strictly administered lower doses at regular intervals remains the criterion standard. Moreover, this study supports the idea that the doses studied should be considered for routine administration in severe pain protocols.
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Affiliation(s)
- Vincent Bounes
- Pôle de Médecine d'Urgences, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
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Predictors of pain relief and adverse events in patients receiving opioids in a prehospital setting. Am J Emerg Med 2010; 29:512-7. [PMID: 20825821 DOI: 10.1016/j.ajem.2009.12.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 12/08/2009] [Accepted: 12/09/2009] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The aim of the study was to analyze factors predicting pain relief and adverse events in patients receiving opioids for acute pain in a prehospital setting. METHODS In this prospective, observational clinical study, adult patients with a numerical rating scale (NRS) score of 5 of 10 or higher who required treatment with intravenous opioids for pain control were included. The primary outcome variable was final analgesia defined by an NRS score of 3 of 10 or lower upon arrival to the emergency department. Univariable and multivariable analyses were performed to identify predictive factors of pain relief and adverse effects. RESULTS In total, 277 patients (age, 49 ± 22 years), 205 (74%) of whom were male and 154 (56%) with a traumatic pain were included in the analysis. Median (interquartile range) NRS scores at baseline and at discharge were 8 of 10 (7-10) and 3 of 10 (2-5), respectively. The final model had 3 independent variables reaching significance. Physician-staffed ambulance transportation (odds ratio [OR], 2.42; 95% confidence interval [CI], 1.07-5.49) was the only independent predictor of patients' final pain relief. High initial pain scores and acetaminophen use were predictive factors for failure of analgesia (OR, 0.79; 95% CI, 0.68-0.93 for one unit/10; P < .01; and OR, 0.40; 95% CI, 0.21-0.77; P < .01, respectively). In the entire sample, 25 (9.0%) presented one adverse effect, all mild to moderate in severity, with no significant predictive factors. CONCLUSION Despite advancement in prehospital pain management, pain relief at discharge is still inadequate in some patients. Finally, one important message of our study is that patients in pain have to be transported by well-equipped and staffed ambulances to reevaluate and alleviate pain.
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